A baby boy was stillborn after ‘over-optimistic’ midwives managed a mother’s labour ‘without actually assessing the patient’ and not having her full medical history to hand.
Maternity staff at the Diana, Princess of Wales Hospital in Grimsby, North Lincolnshire, failed to treat Stephanie Broadley’s labour as ‘high-risk’ as staff suffered ‘task blindness’ having read earlier pregnancy notes referring to her requesting a home birth.
This ‘altered the perception of risk’ of maternity staff and led to them failing to follow guidelines, a Serious Incident Investigation found.
Mrs Broadley, 28, lost her baby boy Beau when he was stillborn in May 2018. Determined to get answers, she instructed Hudgell Solicitors’ Medical Negligence team to investigate, with legal representations leading to the Trust admitting to a ‘breach of duty’ and errors in her maternity care.
She is sharing her story as she is passionate about maternity standards being improved both locally and nationally. She said:
I repeatedly said that I knew something was wrong and there were three occasions when I was in labour that I reported to midwives that I couldn’t feel any movements at all, but no action was taken.
They didn’t increase heart-monitoring, even when I lost blood and it was a funny colour, and they didn’t call for a consultant to see me. Midwives just kept telling me everything would be fine and that it was normal, but I knew it wasn’t.
When Beau was stillborn it was absolutely heart-breaking. I just held him in my arms and sobbed, and it is so difficult thinking back now because I feel like I let him down. I feel that I should have shouted out for him more.
I was repeatedly saying that I didn’t think things were right but now I wish I had been more forceful and loud. The problem is that you place your trust in the people who are there to care for you.
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Investigations revealed midwives wrongly assumed pregnancy was ‘low-risk’
Investigations revealed that staff at the Grimsby Hospital had wrongly assumed Mrs Broadley to be a ‘low-risk’ case when she went into labour at 36 weeks pregnant in May 2018.
This was because her pregnancy records referred to her having requested a midwife-led home birth earlier in her pregnancy.
She was in fact a ‘high-risk’ pregnancy, as two of her previous five children had been born before reaching full term – one of whom needed treatment for an infection – and she had already expressed concerns over the reduced movement of her baby twice.
The Serious Incident Investigation carried out at the Trust said the assumption of her being of low risk led to maternity staff suffering from ‘task blindness’.
It said the references to a planned home birth had ‘altered the ‘perception of risk’ of staff and led to them failing to follow guidelines for treating mothers whose waters break before 37 weeks.
This meant she was not given antibiotics to prevent infection, and blood screening was not carried out as it should have been.
The investigation concluded that this led to ‘over-optimistic’ records being written down, which failed to reflect the growing risk to baby Beau, and meant increased monitoring of his heart rate was not carried out as required.
The report said that ultimately key decisions were being made ‘without actually assessing the patient and not having the full history’.
Criticisms were also made of a failure to escalate concerns to a consultant for high-risk antenatal patient review and was a two-and-a-half hour delay after a midwife had requested a registrar review.
Solicitor says basic maternity care guidelines were not followed
Solicitor Sam Gardner, of Hudgell Solicitors, is currently negotiating with the Trust over damages relating to Beau’s death and says such cases are always difficult.
The hardest thing for any parents to understand and accept is that their baby has not come home with them from hospital because maternity staff have not cared for them as they should,” she said.
In cases such as this it is never about compensation, but holding Trusts to account for their actions and making sure such incidents are fully investigated.
Parents want answers, but sadly we all too often see the same conclusions, that avoidable errors were not prevented and basic guidelines were not followed.
Mrs Broadley revealed she has since learned of the other similar case, at the same Trust, just seven months before Beau died.
A Serious Incident Investigation in that case concluded that staff at Scunthorpe General Hospital failed to act appropriately to the mother’s raised blood pressure during labour, taking her risk from low to high.
This change of risk was not documented and only communicated verbally, leading to her not being medically reviewed and the baby’s heartbeat not being constantly monitored as it should have been.
Delays in acting upon a lack of traceable heartbeat in physical examinations were also highlighted.
That investigation was carried out at the Trust and completed just five months before I went into labour with Beau, but clearly nothing was learned across the Trust from it.
Given the ongoing reviews we have seen at other trusts due to failings to learn from mistakes, it makes me think there should be wider investigations into many other trusts. They can’t be allowed to keep failing families.
The sad thing is that we are seeing this continually happen all over the country and it has a devastating impact on families like ours for the rest of their lives. My husband Lee still can’t face talking about losing Beau.
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The Baby’s death did not meet the criteria for further independent investigation
Mrs Broadley has also been annoyed that Beau’s death did not qualify for further investigation as part of the independent ‘Each Baby Counts’ programme, led by the Royal College of Obstetricians & Gynaecologists.
Beau was just four days short of 37 weeks, the eligible age to be investigated as part of the scheme when he was stillborn.
We have the ‘Each Baby Counts’ initiative, but how can that be effective if it excludes a large proportion of baby deaths like Beau’s. That needs to be extended,” she said.
I am furious that significant changes to maternity are not being made. Midwives are undertrained and maternity units are understaffed.
Mrs Broadley and her husband Lee, 30, have been fortunate enough to have six healthy children, Logan, 10, Max, 8, Tyler, 7, Layla, 5, Teddy, 3 and eight-month-old Arlo are currently looking forward to another baby sister arriving.
However, Mrs Broadley admits that given the heartache of losing Beau, all will only be happy when the new arrival is settling in with them all back home. She said:
What happened with Beau has sadly left me mistrusting of hospitals. There are just too many cases, and too many scandals nationally and big changes need to be made.
We are fortunate in that we have six lovely children, and another on the way, but we had suffered a miscarriage before Beau and he was going to be a rainbow baby, that’s where his name came from.
Losing a baby because of the mistakes of health professionals is not something anybody should go through.
If you have been affected by any of the issues within this article, please visit our birth injury page for more information or contact one of the team here to talk further about your experience.
